What is the prevalence of Axis I and Axis II diagnoses?
Their prevalence is also difficult to estimate. Some studies have demonstrated that transgender individuals may be at increased risk for psychosis, depression, and HIV infection, and their suicide risk is 9-fold higher than that of the general US population.9,10 In a large-scale nationwide study of more than 6400 transgender individuals, 41% of respondents reported attempting suicide—a rate that is 25 times higher than that of the general population.11
One San Francisco study found the attempted suicide rate among more than 500 transgender persons to be 32% for both MTF and FTM participants. The researchers urged the need for intervention at an early age when their results demonstrated a correlation between this percentage and multiple independent psychosocial insults that typically start in a transgender person’s childhood.12
What are the requirements for transgender persons to begin transition-supporting hormone therapy?
As with many questions in this field, the answer to this one has evolved in the past decade. In the past, criteria for hormone use included consistent real-life experience as the desired gender for 3 to 12 months, psychiatric evaluation, and psychotherapy for 3 months or longer.11
Criteria for hormone therapy, according to WPATH Standard of Care (SOC) version 7, require evaluation and referral by a mental health provider who has observed persistent and well-documented gender dysphoria; capacity to consent for treatment; demonstrable knowledge of the risks, benefits, and limitations of hormone therapy; age of majority in a given country; and otherwise stable, well-controlled medical and mental health.6 These criteria are flexible clinical guidelines for which individual consideration is taken, and fulfillment of one or more criteria may be waived in certain patients, such as those for whom prescribed hormones are expected to help control symptoms of comorbid psychiatric illness or prevent use of illegal and uncontrolled hormones.6,13
The newest approach, the informed consent model, has been adopted by medical providers throughout the world.14 With this model, obtaining informed consent is the first step in starting hormone therapy. This ensures that the patient understands all risks, benefits, psychosocial implications, and limitations of hormone therapy within the context of his or her age, previous experience with hormones, and concurrent medical and mental health concerns. Screening for mental health concerns and the capacity to consent is also incorporated into this model. The main difference between the two protocols is that WPATH SOC recognizes a role for mental health providers throughout the process, whereas the informed consent model encourages the use of mental health services only when requested or when significant impairment is evident, thereby contraindicating the initiation of hormone therapy.6
Are there studies that demonstrate evidence of neuroanatomical differences between transpersons and nontranspersons?
The transgender community and many scholars advocate for the declassification of GID as a psychiatric disorder. Studies of the past 15 years have demonstrated that many transgender individuals share certain brain structure similarities, such as shape, size, and density, with their targeted-sex counterparts.15,16 These studies have especially implicated limbic nuclei, such as the bed nucleus of the stria terminalis, as a major source of the body-gender identity discordance felt by transgender individuals.15,17 Observations of this nature have been appreciated outside of the influence of exogenous hormones and gender-affirming surgery. Hence, the notion that gender dysphoria is a product of a neuroanatomical congenital anomaly is developing and being further explored.
Do exogenous hormones exacerbate mood swings?
In your outpatient practice, you have been caring for a 34-year-old transman who has been stable while receiving testosterone for 2 years. He calls your office in distress, complaining of recent episodes of agitation and mood lability. He worriedly asks if the symptoms are related to his prescribed hormone regimen. How do you approach his question?
No systematic studies have been performed to answer this question. However, clinical experience demonstrates that adverse reactions, especially related to mood, are more likely to occur during the initiation of hormone therapy. Transwomen who start a regimen that includes estrogen may demonstrate symptoms of increased mood reactivity. Similarly, transmen who begin testosterone therapy may experience increased energy and psychomotor agitation. After initiation, hormones are titrated to achieve physiological levels of the target gender, and they are regularly measured to ensure maintenance within the appropriate physiological ranges of either testosterone (320 to 1000 ng/dL) or premenopausal estradiol (less than 200 pg/mL).18 In our experience, when hormone levels are within physiological range, adverse psychiatric symptoms are generally mild and far outweighed by the hormone’s positive gender-affirming effects and resulting mood stability. When hormones reach supraphysiological levels, they are more likely to contribute significantly to psychiatric symptoms.19